Informed Consent for Procedure

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Fields marked * are required. Your entries stay on this page until you submit; they are not saved automatically.

Full legal name *

1. Are you pregnant or nursing? *YesNo

2. I absolutely understand and accept that such procedure is a process, often requiring multiple applications of color to achieve desirable results and 100% success cannot be guaranteed. Your initials: *

3. I have received, reviewed and understand the procedural instructions as given to me and agree to follow them. Your initials: *

4. Depending on the procedure(s), which I select, I accept responsibility for determining the shape, and position of eyebrows, lipliner and/or full lip color. Your initials: *

5. I understand that the color selection and color results in all procedures are not an exact science. Your initials: *

6. I understand that positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery, Botox or Restalyne and I assume this responsibility. Your initials: *

7. I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics. Your initials: *

8. I understand that this procedure will fade and this fading can alter the original pigment color and that this determines the time for a touch-up visit. Your initials: *

9. I realize this is an elective cosmetic procedure and is not medically necessary. Your initials: *

10. It has been explained to me that the following possibilities may occur: Minor and temporary bleeding, bruising, redness or other discoloration; swelling; fever blisters on the lip area following lip procedures and/or fading or loss of pigment. Your initials: *

11. I understand that many lasers & IPL's (Intense Pulse Lights) including those used for Photo Facials, removal of lines may or will turn permanent make up dark or even black. I agree to inform my esthetician or anyone operating such that I have permanent make up. Your initials: *

12. I give my consent to Glow Co. L.L.C. to confer with my physicians for medical information required for the safety of my procedures. Your initials: *

13. I agree to accompany my practitioner to the emergency room in the event they were to be accidentally stuck with my needle and take a blood test for their safety & disclose all test results to my practitioner. Your initials: *

14. I have read and understand these risks listed above and they have been explained to me. I certify that the information in the questionnaire is accurate and my questions have been answered. Your initials: *

Review and sign

Your signature applies to the original form and the completed response record. The studio completes its section separately.

I have reviewed the complete form and my answers. I intend my typed name below to be my electronic signature on this document. I agree to receive this signed record electronically and can download and save a PDF copy. My answers are accurate to the best of my knowledge. For informed consent, I also confirm the risks have been explained and my questions have been answered.

Electronic signature — type your full name *

The signing date and time are recorded automatically. Contact Melissa if you prefer paper forms.